How to manage type 1 diabetes to live a long, healthy life
Intro
This guide is based off of my experiences, of those shared by others on reddit, and various studies which are linked.
High blood sugar is a dangerous monster. It leads to countless complications within a few years or decades. Short term you will have worse sleep, worse memory, lower IQ. I track my sleep quality using a fitbit. The nights I have high blood sugar, 108mg/dl+ or 6mmol+, my sleeping heart rate is higher, indicating worse sleep. In the long term high blood sugar causes all sorts of issues, from kidney damage, digestion issues, heart disease, eye damage. You name it.
I saw a video of a 29 year old girl in the UK on the NHS website, type 1 since age 2, who started getting complications from age 20. At the time of the video, she is on a waitlist for a kidney and pancreas transplant. She had a burst vessel in her left eye causing the eye to go blind. She also has gastroparesis, her stomach basically has digestion and bloating problems. Here is the video: https://www.youtube.com/watch?v=AnKQdSW98p4.
The best and worst case of type 1 are on opposite sides of the spectrum. Best case, you have no complications, you live a full, healthy life with max of 10 minutes of management a day. This is me right now and it's barely affecting my life. On the other hand, the worst case is you go blind, need a new kidney, feel tired all the time, have bad sleep. Not only will you die earlier, the time you are alive is significantly worse. The average type 1 lives around 8 years less than average: https://www.hcplive.com/view/average-life-years-lost-from-type-1-type-2-diabetes
I believe a nondiabetic blood sugar average is achievable for 95%+ type 1's with just 10 minutes a day like me. There are only a few things to remember. I am fortunate in that I have enough insulin production to cover my long acting needs and that makes controlling my long acting much easier. The sooner you stabilize your sugar level, the more insulin production you will preserve. Some people do have it harder though such as woman with monthly periods or steroid medication users that cause their insulin needs to fluctuate. But once you observe your body patterns and react accordingly, I promise it'll become second nature.
Most endocrinologists don't care much about their patients having a truly healthy blood sugar, which is a nondiabetic a1c. They just go with American Diabetes Association (ADA) recommendations, which says as long as you are under 7% a1c, written on page 12 here, you are good. Dr.Bernstein, an endocrinologist who is also type 1 himself and became a doctor because the advice he was getting was causing him a lot of suffering, said this is a unscientific, padded number to protect doctors in case patients die from low blood sugar and the doctor gets sued. They don't give adivce to help the patient but to save their own skin, with unrealistically paranoid advice. If you have a 6.5% a1c (average level of 7.0 or 126), the average endocrinologist will tell you that's good even though this study shows you are at 3x the risk of getting a stroke. Look at Figure 2, bottom left graph: https://www.nejm.org/doi/full/10.1056/nejmoa0908359. All cause death is 1.8x higher. I bet most endocrinologists never laid their eyes on this study. And if one did, why are they hiding it? Most are either clueless or dishonest.
If you want to know how little many endocrinologists know about type 1 diabetes, skim through this post: https://www.reddit.com/r/diabetes_t1/comments/12f61ga/anyone_know_a_good_endocrinologist_who_is_also_a/
Dr.Bernstein is one of the few doctors, not just endocrinologists, who knows anything over a nondiabetic a1c will harm you significantly. He has been type 1 for 70 years since age 10. And of that, for 40 years he maintained nondiabetic a1c ever since he cracked the code. He reversed his gastroparesis and severe kidney damage by maintaining a nondiabetic a1c. He has a youtube channel explaining type 1 diabetes and all the associated risks.
My endocrinologist and diabetes educator were quite useless in teaching me about managing type 1. My diabetes educator in the first and only session I attended never mentioned: 1. looking at the the nutrition label and 2. weighing my food using a scale to count the number of carbohydrates in my food. These 2 ways are the most accurate way to carbohydrate count. I'll call carbohydrates as carbs for short. She only mentioned an inaccurate measurement of using your fist or a piece of food, i.e. 1 apple is 15 grams carbs. But a big apple is double the weight of a small apple. It makes no sense using this method. It's meant for type 2 diabetics who don't need high precision when injecting insulin.
Regarding my endocrinologist, he couldn't recognize from my graph that my lows were post meal, because of the rise right before I dropped low. He had no idea how to analyze a blood sugar graph. He misleadingly recommended me to lower my long acting by 1 unit which wouldn't affect my post meal lows. He also didn't know what a compression low was for glucose sensors (laying on top of your sensor can cause fluid to move away from it, causing it to read low mistakently). When I mentioned it when saying some of my lows were false lows, he asked what a compression low was, and after explaining it, he still seemed skeptical. Within a week of having a glucose sensor I knew what a compression low was. Here is his ratings actually: https://www.ratemds.com/doctor-ratings/3488758/Dr-Andy-Suk-Toronto-ON.html/. The oldest one is from 2012 which means he has 10 years of experience. Ironically he is chief endrinologist at a big city hospital (Mississauga hospital).
Searching the internet, there was no concise guide to all of this when I was learning about the disease. The diabetes websites have so much pages with a lot of scattered and fluff information. Therefore, I give you this guide, from real experiences and analysis, in the most concise guide you will find on the internet.
Overview
When asleep or awake, you want to be 72-100mg/dl or 4-5.5mmol. Ideally in the 4's. During the day you will be in the 5's and higher which is fine since meals will make you rise more. This will give you the a1c of a nondiabetic along with no long term complications. A 5.0-5.4% a1c is optimal according to this study, figure 2.
You probably are reading this soon after diagnosis. You have been at a very high blood sugar for at least a couple weeks so your body is used to a high sugar level. Normalizing your sugars to 72-100mg/dl or 4-5.5mmol may make you feel weak and nervous. I've read 2 separate stories on reddit of this happening. In that case, take a gradual approach and bump up the range I gave by 20%, and gradually decrease to the optimal level over 2 weeks. 2 weeks after diagnosis, I normalized my sugar level and felt no shakiness at the optimal range.
a1c and average blood sugar are 2 different measurements. a1c measures how much of your red blood cells have a glucose molecule attached to them. An a1c of 5.3% means 5.3% of your red blood cells have a glucose molecule on them. Glucose is a highly reactive substance so it attaches to different cells such as red blood cells, many times causing damaging byproducts, source. You can guess what happens at a high sugar level. Your average sugar level on the other hand is the average level you had over a period of time. They are related but it's not 100% linear, someone with an average of 104 (5.8) could have an a1c of 5.3% or 5.0%.
You most likely have some of your insulin cells remaining upon diagnosis according to this study, figure 3. The older you are, the more insulin cells you likely have remaining. A healthy sugar level helps reduce the immune attack on insulin cells according to this study. High sugar causes your immune system to go wack and increase it's attack on your insulin cells. If you maintain nondiabetic sugar levels, you can maximize the preservation of what you have left and this will make your sugar management easier for the rest of your life. Your cells also can regenerate to a certain degree since they are cells after all, source. Dr.Bernstein in one of his videos mentioned a patient he had who maintained a nondiabetic a1c since diagnosis. For 20 years and counting, she only had to take a small long acting Lantus dose of 8 units nightly. 25-50% of what a type 1 usually needs. Dr.Bernstein says he saw this with multiple patiens of his in this video.
Usually your remaining insulin production wanes over time. This study shows the decrease in insulin production of type 1's over 4 years.
Keeping a nondiabetic a1c requires some self control. Now I eat 130g of parboiled rice with each mile as opposed to about 170g of white rice before. Parboiled rice digests much slower, even slower than brown rice, while tasting just as good as white rice. 130g of cooked parboiled has 30g carbs which I inject 3 units of fast acting Admelog for it. I eat that much for lunch and dinner. In the morning my insulin resistance is high and only works 1/3 as well for the first 2 hours. So for breakfast I only drink a glass of water.
Food
Get a food scale so you can weigh your food. Weighing is the most accurate measurement. Your diabetes nurse will probably give you some crappy teaching about using your fist size or using cups to measure food. This is imprecise and is meant for type 2 diabetics, who usually don't inject insulin. When you inject insulin, you want very high precision, 90%+.
For food, you want to stick to low glycemic foods, foods that release sugar slowly when digested. Processed foods like crackers will digest quickly. In a meal, you may want to eat the protein and fat before you the carbs. This makes the release of sugar from the carbs slower, as shown in this study. Although if the meal is healthy as a whole, you can eat it in any order. I don't eat my food in any order and my sugar graph only shows a bump.
Dr.Bernstein advocates for a low carb diet of 30g or less daily. I find this too low, I eat about 80g a day and got a 5.1 a1c 3 months after my diagnosis. If you run into any problems with management, lower your carbs. I once had to when my insulin needs unexpectedly doubled for 3 weeks. Eventually went back to normal after that.
I do notice that the higher carbs in a meal such as 40+ grams, the higher I spike. This makes sense as more sugar is released into the bloodstream. But you can control this in other way such as splitting up your short acting or injecting 15 minutes before eating.
Here is a study done on 48 type 1 diabetics showing the beneficial effect of having a diet of 75g or less carbs daily. 23 people adhered to the diet and their average blood sugar was way better.
When looking at the nutrition label, the carbohydrates section is what you want to look at. Subtract the fiber from the total carbs to get the net carbs. So 32 carbs - 5g fiber = 27g net carbs. Insoluble fiber doesn't get digested.
2 websites I like for nutrition labels is fatsecret.com and nutritionx.com If you google "net carbs in 100g banana", chances are you will come across these. Make sure you always look at the fiber to calculate the net carbs. I once googled "carbs in 100g peanuts", and I found it was 16g on the automatically suggested google result. I injected insulin for 16g carbs and an hour later went into a hypo. Why? Because 100g peanuts has 8g fiber as well so it's actually 8g of net carbs. That's what goes into your blood.
After your meals, make sure you are sitting or standing for at least two hours so the meal digests properly. Laying down after eating will inhibit digestion. Source. Not a hard rule, but it can make a difference.
Don't eat within the last 3 hours before sleeping. You want your blood sugar to stabilize before sleeping so you know you are going to bed at a good level. And if you are not, you still have time to correct. I say 3 hours because if you sleep at 9pm and last eat at 6pm, 1.5 hours in you can see if the insulin was enough. And then you have 1.5 hours to see if your correction dose was enough to bring you down by 9pm.
You may spike in your sleep starting around dawn. This is something called the dawn phenomenon. Your liver releases extra sugar in anticipation of the day starting. Your body also releases certain hormones at this time. You will probably have much higher insulin resistance in the morning. I recommend eating a no carb breakfast such as eggs or none at all. Along with a glass of water. Here is a study if you want to learn more.
Don't drink water from 30 minutes before eating a meal to 30 minutes after eating a meal. Drinking water then will increase your post meal glucose level by 1-2mmol higher than without water. This is because water makes your stomach empty faster, so all nutrients such as sugar reach the intestines faster. This was observed in 2 studies, one with donuts, and another with meat and potatoes:
Donuts: https://link.springer.com/content/pdf/10.1007/BF00285289.pdf
Meat and potatoes: https://clinicalnutritionespen.com/article/S2405-4577(18)30375-9/fulltext. Not a hard rule though, see if it makes a difference for you.
You want to avoid alcohol as a type 1 diabetic. Study about it: https://pubmed.ncbi.nlm.nih.gov/15460663/. This says "alcohol intake at 2100 hrs significantly reduced blood glucose values after 10-12 hours, compared with control studies with no alcohol." Yup, 10 hours later you can go into a hypo.
When you drink alcohol, liver gets busy removing it from your blood. This causes it to slow down it's release of sugar. If you are using insulin pens, there is still long acting insulin in your body so your blood sugar will drop unexpectedly. People on reddit always mention this. If you are on a pump, it's more manageable since you can decrease the short acting but still a challenge. Reddit has tips from people who are able to drink it. I've read some say it's so hard to manage they stopped drinking completely.
Alcohol is a neurotoxin anyways. You wanna kill your brain cells just to be drunk? Be sane, don't drink a toxin.
Insulin
Insulin is a protein that also acts as a hormone by attaching to receptors on a cell that make it take in glucose. Proteins are made up by 20 possible amino acids. Insulin is made of 51 total amino acids, arranged in 2 chains that are attached side by side.
Glucose is the primary source of energy in your body. Most of your cells cannot take in glucose by themselves. They have a insulin receptor on them which makes them take in glucose when a insulin molecule attaches to the cell. Kidney cells and brain cells are an exception, which means they are more prone to complications with high blood sugar.
There are 2 types of insulin you'll have to inject: fast acting and long acting. Fast acting is for meals and works actively for 1.5 hours (in my experience). If I exercise, it works even stronger for up to 2.5 hours. Length of action may differ for you. Long acting works over 24-48 hours depending on the brand. You always need some insulin in you to allow your cells to take in glucose.
Here is a table showing the acting times for each insulin.
I recommend Admelog for fast acting insulin, 30% lower cost and idential to Humalog. Admelog and Humalog actually have the same exact molecular structure, Insulin Lispro. I recommend Basalgar for 24 hour long action, 30% lower cost and identical to Lantus. In Canada both insulins are approved as biosimilar to their counterparts, meaning they've been tested to work to the same effect. If your insurance covers both I recommend switching anyway to the cheaper insulins so insulin companies are pressured to lower prices.
If you are in the US, you can get insulin for just $35 monthly with this coupon.
Insulin to carb ratio, shortened to IC ratio, means how much carbohydrates 1 unit of fast acting insulin covers. An IC ratio of 1:10 means 1 unit of fast acting covers 10g of carbs.
Correction factor means how much 1 unit of insulin drops you. A correction factor of 1:54 means 1 unit drops you by 54mg/dl. If mmol, 1:3 means 1 unit drops you by 3mmol.
Make sure to count the number of carbs in your meal and dose your insulin to the carbs. I recommend starting off with a IC ratio of 1 unit for every 10 carbs. You can test this with any packaged food that you are confident has an accurate nurition label. I use 250ml of whole milk which is 13g carbs. I see if drinking 250ml of whole milk and injecting 1 unit of fast acting insulin makes my sugar level 2 hours later the same as before drinking the milk. Make sure you do not do anything streneous on the body or walk more than 40 meters at a time 2 hours post-drinking. Or get nervous or sad or other than calm, as your heart rate can affect your blood sugar. If your 2 hour post milk sugar is within 4mg/dl (0.2mmol) away than your pre milk level, perfect, your IC ratio is 1:13. If not, you can estimate of what your exact IC ratio is or retry with a more or less milk.
Protein and fat causes your sugar to rise theoretically over a few hours through a process called gluconeogenesis, where they are converted to glucose. For large protein and fat meals be aware of this, you may rise slowly for a few hours later.
Some high fat foods like pizza will digest slowly. Don't inject right before you eat else you will go low. Take half before you eat and the other half when your sugar starts rising again, for me that's 30 minutes later. You might have to experiment.
You may see the advice to take insulin 15 minutes before you eat. I inject mines right before I eat and it works well. I usually don't spike above 126 (7) for a meal. My average lunch/dinner is 33g of carbs, 3 units.
Inject insulin in areas where you can feel the fat by pinching the skin. Blood shouldn't come out when injecting as it means you hit a blood vessel which are abundant in muscle. Blood can come out in fat if there is a blood vessel in it.
The area below your belly button has more nerves so it may be painful to inject there. I don't inject there after I felt pain the first few times. You'll get a feel of which parts of your stomach are more painful than others. I avoid the painful ones.
Every time before you inject, you could push out .5 or 1 unit of insulin. I don't do this anymore actually, I just check after I inject if a drop forms at the end after taking it out and still pressing on the knob. That means the needle was not clogged. Sometimes it can get clogged due to dried up insulin crystallizing overnight.
To minimize pain when injecting, insert the pen in a fast motion. Like a wrist flick. It will go through fast. Going slow also hurts more. Once in, push your thumb down firm. You want the insulin to go fast in the fat. Leave it in for a few seconds before taking it out. No need to stay in for 10 seconds, that's too long.
The packaging says insulin must be thrown away 28 days after first using it. This is padded. It can last for months at room temperature. On reddit and diabetes forum I've read of people using years old insulin that worked just fine. The durability of insulin past the 28 day limit is well confirmed in a study that tested all kinds of insulin, short and long acting, all cycled from 25-37C for 2.5 months. The median temp was 31C and at the end all insulins had 99.4%-100% concentration left. Look at table 1: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7857579/.
When you go outside or travel, as long as it isn't super hot such as more than 31C, according to the study right above, there is no need to keep it cool. Don't let your insulin get frozen either as that will break the protein structure and spoil it. I went travelling once and left it in my pocket.
In 31C+ environments, a cooler with ice works.
Periods and sickness and DKA
For women, periods will probaby change your insulin resistance. This guide explains it: https://www.diabetes.org.uk/guide-to-diabetes/your-child-and-diabetes/periods. You will have to track your periods and react accordingly to how your insulin resistance changes with your period.
Being sick will probably increase your insulin needs, short and long acting. I need about 50% more bolus per meal when I am sick. I read others have increased needs as well on reddit. I read a post that said some people had children who needed less insulin when sick. So adjust accordingly.
If you travel and will be exposed to a lot of people in a airplane or outside, consider using elderberry supplementation to reduce the chance of getting sick and shortening the length of sickness. I got this trick from Dr.Bernstein. Elderberry has antibacterial and antiviral propertise. In one study of 325 travellers, elderberry capsules reduced the average length of sickness by 2 days and significantly reduced the severity of symptoms: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4848651/.
If you cannot get your blood sugar down despite injecting and are experiencing major signs of DKA such as vomiting, go to the ER. Vomiting and pain in the stomach are 2 of the most common signs of DKA, source.
Hot temperatures will make your sugar level rise gradually. This happens to me in the summer when it gets hot. According to this article I think it is because heat makes your body creates glucose from proteins and fats quicker: https://www.nutrisense.io/blog/how-heat-and-humidity-affects-your-blood-sugar-7-tips-for-beating-the-heat
Needles
You can reuse needles, I use 1 per day. According to this study you will be good for multiple injections. Replace the needle if you feel more pain than usual. Or if it won't unclog.
On reddit someone said: "I've been diabetic for 37 years. I've used 1 needle a day for multiple injections and have never had an infection or any problem." I was diagnosed Dec 2022 and haven't had any problems since. Will update this article if I do ;).
Generally around 5 uses does the needle get blunter and more painful. That's why I use it for a day for my bolus. If you reuse needles on your long acting over multiple days, the insulin will probably crystallize in between uses. One tip: put your pen in a cool environment overnight as that slows down crystallization, source. You can put it in the fridge if it's big enough of a issue. Cold insulin stings though. I leave mines in my bedrom.
I leave the needle on my long acting for 7 uses which lasts 7 days. I find that in between uses, the needle gets clogged and needs at least 3 units to unclog. But if I inject my full dose of 8 units, it will unclog while injecting. I can see after pulling out, while still pressing down, and seeing a bit of insulin dripping off the needle. This trick saves you some insulin by not having to unclog before injecting.
If needles are not covered by insurance, you can save money on needles by using any other brand than BD Nano. I'm in Canada and I use the Oracle brand from amazon, 32G 4mm which are 40% cheaper, sharper, and better than BD Nano. I find BD Nano needles to dull faster and "stick" on the way out.
Med fine needles are the cheapest and have good reviews. If I was in the US, I'd buy them.
You can put used needles in any plastic bottles. A milk or juice jug is a good size and put the lid on when it's full. No need a special sharps container. Toss in trash.
Blood test strips
An accurate glucometer is crucial since your glucose sensor will be calibrated based off the glucometer. The glucometer I recommend is the Relion Premier Compact. The test strips it use are Walmart ReliOn Confirm/Micro. 100 strips is $32 USD. This glucometer is accurate and best value according to this study: https://diatribe.org/are-blood-glucose-meters-accurate-new-data-18-meters. Other ones on the list are about $50 USD per 100 strips.
No need to change the lancelet every time you test, waste of time. I change it it every couple months when it becomes noticeably dull.
Wipe your hand before pricking your finger. No need to wash with soap and water unless there is visible dirt.
If you ever need to buy glucose sensors or insulin pump supplies out of pocket, a cheap site is https://teststripz.com/.
Long acting
Your body always needs some insulin and glucose in your blood so your cells can take in glucose. Your liver and pancreas therefore slowly release glucose and insulin around the clock. You can't make much insulin so you have to inject it instead, which is known as basal or long acting insulin. Upon hitting fat, it forms crystals that slowly release insulin.
Your insulin resistance varies due to hormones. It is highest from 3am-8am, 25% higher than usual according to this study. Look at the bar chart in figure 1: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6008663/. Your liver also releases more sugar in the morning. The combination of more sugar released + hormones released make insulin work worse. This is called the dawn phenomenon. It has to be countered with the right dose of basal insulin. I don't experience it though due to having a good amount of insulin production left which covers it.
The brand Lantus is advertised to last for 24 hours but lasts a couple hours less according to Dr.Bernstein. Basalgar is basically the same as Lantus but 40% cheaper. Dr.Bernstein recommends splitting your total Basalgar/Lantus dose in 3 parts and injecting at different times. This ensures there is always a consistent amount of long acting in you. You may be able to get stable nightly sugars by just injecting Basalgar once or twice a day instead of 3. I inject just once at night. Keep in mind a lot of this is experimentation so see what works best.
He has a full video about him talking about basal insulin: https://www.youtube.com/watch?v=6lrbxITXAVA
In the video above he says to "split your dose twice", which means the original dose plus the 2 split doses to, for a total of 3 doses daily. Here is a full article of how someone uses Levemir, another long acting insulin. No need to read but is interesting to skim over: https://theinsulintype.com/2018/10/03/splitting-levemir-basal-insulin/.
To maintain my goal of a sugar of 90 (4.5), I went from needing no basal to needing at least 7 units a night, 8 months after diagnosis. Even if you are stable without basal, inject. The less insulin your body has to produce, the more insulin production you preserve. I lost some due to not injecting basal early on.
Dr.Bernstein in in his Diabetes University playlist said that he uses a 42 hour insulin called Tresiba. If you use it, use the generic verstion to save money as it is the exact same as the brand name insulin. Tresiba is more expensive and is advertised to last for 42 hours so you can inject less often. That may mean you can get away with injecting just once a day vs. Basalgar.
Inject long acting in the fatty parts of your upper butt and inner thigh (towards your stomach). Upper butt so that when you sit you don't sit on the crytals. You will need to adjust your long acting based on how your sugar levels trend in the night. You want your waking sugar level to be about the same as your pre-bed sugar level. If you wake up at least 18 (1mmol) away from your before bed level, increase or decrease your long acting by 0.5 units. Or 1 unit if your pen doesn't dose in 0.5.
Your daytime basal needs may be different. To figure out how much you need in the day, fast, meaning only drink water, and observe if your sugar level is stable throughout the day. Eat at 6pm.
It is possible to inject long acting into a vein instead of blood by accident. In this case the insulin won't crystallize and will be released directly into your bloodstream. This is dangerous and will cause you to drop rapidly. Is usually called a Lantus low. I've read a few stories on reddit of that happening. Make sure you inject into the fatty areas or else this wll happen. Never happened to me.
Some people accidentally inject their short acting in place of their long acting due to mixing up the pens. In that case, you can calculate how many grams of sugar you need to cover that much insulin and mix it with water and heat to make syrup. Sip the syrup over 30 minutes. Someone on reddit did this and it saved them a hospital trip, I can't find the post, it was sometime June 2023.
Short acting
When injecting fast acting insulin, take your adomen and it's sides and divide it in 7 vertical regions of equal width. Make the left most Sunday, and for every next day, keep on going right, with the right most being Saturday. At the beginning of the day, inject in the topmost part of the region with fat. As the day goes on, inject further down. This ensures that you won't inject in the same spot for at least 7 days. I read of a story on reddit of someone who's sister, type 1 for 7 years, had built up scar tissue due to injecting in the same place(s) continuously. She got swelling there and insulin there did not work as well. He said she was crying a lot because of it. Link
1 unit of fast acting drops me by 3mmol or 54mg/dl, may differ for you. If your sugar level is 6.5/120+, then you can inject 0.5 or however many units to come back to 72-100 (4.0-5.5). 80-90 (4.4-5) is ideal if you can get it there. You can get much better control if you can get a reusable pediatric insulin pen that uses 0.5 increments as opposed to the pens only doing 1 unit increments. Instead of dropping by minimum 54 (3) with 1 unit, you can choose to drop by 27 (1.5) with 0.5 units. These resuable pens use insulin cartridges. For admelog the JuniorStar insulin pen works. Your local diabetes clinic or endocrinologist may be able to get you a reusable pen for free. They are hard to find online.
When injecting and unsure about how much to inject due to being currently active or post exercise, be conservative. It's less taxing to recover from being high than from being low. Going low makes you feel hungry and tired.
Sometimes after weightlifting my IC ratio changes and sometimes stays the same. When it changes I need 0.5 unit less than my usual 4 units for dinner. I went into a hypo a few times because I needed 3.5 and not 4 units. Now I always take 0.5 less units after weightlifting. With 3.5 sometimes I don't drop back to my pre meal level 2 hours after eating. That's fine, I correct it with 0.5 units.
If you are going to eat something sugary like soda or ice cream, to combat the spike you can you can split your injection into two or more doses back to back. Smaller doses absorb faster than larger doses due to increased surface area exposed to fat. Also, wait 15 minutes before eating. Then the insulin will act earlier.
Low blood sugar, aka hypoglycemia, and correction doses
After injecting short acting insulin, for the next 2-3 hours, doing any movement for more than 1 minute-ish will drop your blood sugar. This includes walking, biking, washing the dishes, etc. Any activity that activates your muscles. The longer you do the activity and the more strenuous, the more the drop. Your IC ratio normally may be 1:10, but when you are physically active it can be 1:30. The 1:30 number is not my measured active IC ratio, someone on reddit shared theirs and I shared that. When moving, the insulin you will not keep working forever as you move, it has a finite amount of effect. But it will have more effect when you are active as opposed to when you are still, hence the higher IC ratio of 1:30.
Once I had a lunch of 44 carbs. Right before eating I took 4 units of admelog. 30 minutes later when I was done eating, I went into my backyard to water the plants and trim some bushes. Before I went, I was at a 83 (4.6). When I came back 10 minutes later, I was at a 60 (3.3). I didn't feel it. 10 minutes of walking about is enough to bring you into a hypo in the 2-3 hour period after injecting. A walk around the block is also enough to drop you.
During mild hypoglycemia, 63 (3.5) and below, I feel a faster heartbeat and weakness. It's the feeling you get when you're nervous. My fitbit shows 20-30 higher beats per minute than normal. The lower I go, the worse the effects. I may also feel hungry. If you are less than 72 or 4.0, eat 4 skittles. Skittles are 1g carbs each.
Sugar with water also works. Or fruit juice. A swig is enough. Skittles are nice when you're outside.
If you think you took too little insulin for a meal because afterwards you rose more than you expected, don't inject more to correct unless you've been at about the same level for at least 20 minutes. Sometimes the food is donuts so it digests really quick, and within 30 minutes you may shoot up from 90 to 180 (5 to 10). But you will come down just as fast. In these cases, you initially injected the right amount and the steep sugar spike is normal. Let the initial insulin do it's work. Wait a bit.
Many times, I shot up quickly and thought I injected too little, so I inject more. But then 30 minutes later I go into a hypo. In reality, the sugar released a lot faster than the insulin. Had I waited 30 minutes instead, I would go back down to my expected sugar level. Be patient and only do a correction dose if you are at the same level for at least 30 minutes. If it is still increasing, don't correct. Wait until your sugar levels out.
Exception to not injecting while you are still increasing is if you are going really high exceeding 180+ (10+). Then it was probably because you took too little insulin. Insulin works worse the higher your sugar level is because of higher insulin resistance. So better to correct early if you are trending very high.
Also 15 minutes after injecting a correction dose, do some squats or pushups for a minute. Small amounts of insulin when correcting tends to need an "activation energy" to get started. Which is exercise. Otherwise, many times it just sits there in my blood. This happened months after my diagnosis when my body became less sensitive to small amouts of insulin.
Don't be scared of lows. They are easily avoidable and your liver will save you. Only doing dumb things like drinking alcohol without strict attention will make you go unconscious. And even if you do go unconscious, this person on reddit mentioned how their endo saw 2 patients recover from it just fine, to quote:
"I just got a pep talk from my endo yesterday about how I shouldn't be afraid of lows because they aren't really that dangerous and kinda come along with tight control. I know you were mostly asking for actual advice here but I figured I'd pass along what my endo said.
First he asked me, "What would happen if you fell in a diabetic coma and no one found you?"
I said, "I don't know, really bad things?"
He said, "Nothing would happen. You would wake up some time later and be fine." And then he told me 2 stories about patients who had casually been in comas on their couches for like 6 hours, after taking a full meal dose and forgetting to eat, and then woken up totally fine."
Endocrinologists are deathly afraid of their patients dying so they will tell them to maintain average higher than nondiabetic levels. Their fear is unfounded.
Sleep
You'll get worse sleep if you don't sleep with a healthy blood sugar of around 72-99 (4.0-5.5). My fitbit inspire 3 showed me that on nights with a average blood sugar of greater than 108 (6+), my sleeping heart rate is about 5 beats higher than on nights averaging less than 108 (5.5). A lower sleeping heart rate is associated with better sleep quality. Stabilize your sugar level by not eating any carbs in the last 3 hours before you sleep. This way you'll have to time to correct in case are high before sleeping.
First 2 hours and last 2 hours before sleep is when your correction factor will likely change.
If it has been around 13+ hours since you awoke, insulin will probably be less effective per unit because of the hormones your body release as you get sleepy. Insulin works 1/3 per unit as well when I feel sleepy or just awoke from sleep. Sometimes my high alarm goes off in my sleep, I wake up, and inject 3 times my normal dose. Test your sleep correction factor with a unit of insulin an hour before you sleep. This is your pre and post-sleep correction factor.
If you took a 1+ hour nap during the day though, though your correction factor may be the same as usual right when you sleep. I noticed this once when I corrected at bedtime but also took a 2 hour nap that same day. Dosed too much and went low as I was sleeping. Corrected and went back to sleep.
When I wake up, in the first 2 hours I need double the usual dose.
The more sleep deprived you are, the more insulin resistance you build up. May be relevant when travelling or doing late nights. Study on it: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9036496/
Exercise
As mentioned before, if you injected short acting insulin in the past 2-2.5 hours, exercising will bring you down fast. Your muscles have an increased need for energy so they are more sensitive to insulin. Your carb ratio may go from something like 1:10 to 1:30. You may go low so keep watch while exercising. I recommend waiting at least 2.5 hours after you last injected more than 1 unit before exercising.
Exercising by doing jumping jacks for 5 minutes can be enough to drop you from 270 (15) to 180 (10) within 30 minutes. I did this once when my sugar was high, worked like a charm.
Exercising, specifically cardio, decreases your insulin resistance for the next 24 hours. Your IC ratio therefore increases. The same meal with the same amount of insulin will most likely make you go into a hypo after exercising. Adjust your insulin to IC ratio accordingly. After cardio exercise, I recommend taking 3/4 of an insulin dose of what you would normally take. I need half a unit less for a meal of 3 units after using my exercise bike for 30 minutes. That's a 16% decrease in short acting insulin needed.
Watch your long acting as well, that will probably decrease in in dosing. You will be more sensitive to insulin in general for around 24 hours.
Weightlifting can possibly cause increased temporary insulin resistance due to hypertrophy. For me it doesn't affect my IC ratio unlike cardio exercise Study observing the effects: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7235686/#:~:text=Some%20of%20the%20studies%20indicate,sensitivity%20%5B13%2C%2014%5D.
If you are outside and walking more than 50 meters, your muscles will use insulin more effectively. I recommend taking a third of what you usually take if you eat before walking long distances or doing something physical. True story, my glucose sensor said I was a in a hypo at 54 (3.0) for an hour while walking in a city once while on vacation. Lesson learned. The next time I went on vacation, I dosed 3 units for a 9 unit meal and then went walking for 2 hours as I explored. My sugar graph showed a flat bump, it was beautiful.
The more intense the exercise, the greater the change in your IC ratio.
More about exercise's effect on insulin sensitivity: https://www.diabetes.ca/health-care-providers/clinical-practice-guidelines/chapter-10#panel-tab_FullText
Glucose Sensor
If you want easy managment and don't want to use test strips every time, you can get a continuous glucose monitor (cgm). It has a wire, a few mm long, that goes through the skin into the fluid inside your fat. It measures the glucose reading there as blood from blood vessels leaks out with a delay of 3-5 minutes, according to a study done by the manufacturer of the libre 2. You will probably use the libre 2 (replace every 14 days) or the dexcom g6 (replace every 10 days). Other cgm's exist but these 2 are used by most. The libre 2 is recommended on the upper back arm but anywhere with fat works for both sensors. The g6 has to be calibrated with a glucometer reading while the libre 2 does not. The dexcom has support for pumps while the libre 2 does not.
My sensor placement of choice is on my belly. Put the cgm on your belly for at least 8 hours before activating it. You do so because it takes time for your immune system to stop attacking it and form an equillibrium of sort with the wire. With the dexcom, put a piece of tape over the sensor connection during those 8 hours so the electric grease doesn't get wiped away by your shirt.
Imagine you drew a verticasl line along your belly button. Don't put the cgm wire within one inch of that line since it will hurt more when inserting. The area below your belly button has more nerves. Imagine you also drew a horizontal line along your belly button. I don't put my cgm above that line because there is less fat.
When you activate it and it finishes the 2 hour warm up time, it will probably read high. Wait 30 minutes to give it some time to go down to your real level. If it doesn't by then, calibrate.
Then you have to calibrate the g6 using your glucometer. Do so when your sugar is stable, no food or insulin in the past 2 hours, such as in the morning when you wake up. Input your calibraton twice in a row with the same value. Doing a single calibration doesn't convince the app as much.
If 20 minutes later it doesn't stabilize at your real level, repeat every 20 mins. Calibrate once daily in the first 3 days of a new sensor, and once 2-3 days after that.
When applying the dexcom g6, after pressing the sensor adhesive onto your skin but before pressing the button, pull back the applicator away from your skin a inch, then press. This prevents the needle from going in too deep and hitting a blood vessel, causing pain and bleeding. I learnt this the hard way.
If you lie on top of your sensor in your sleep, this can push the interstitial fluid out of the area where your sensor reads from, causing your readings to drop quickly. Once you lay off of it, it will shoot up back to normal. These are called compression lows and are not cause for concern.
Your sensor may peel off by day 10. If you have problems with this, you can use a Skin Grip patch from skingrip.com after applying your sensor.
If you use the dexcom g6, you should donate your used transmitters so that they can be modified with a rechargeable battery and reused forever. Here is the project: https://bionicwookiee.com/2021/04/02/anubis-the-g6-reborn/.
Insulin pumps
Here is a good introduction to insulin pumps: https://www.umassmed.edu/dcoe/diabetes-education/pumps_and_cgm/
Pros of pump:
- Fined tuned dosing to manage fluctuations in basal needs automatically
- Helps combat dawn phenomenon in your sleep
Cons:
- Very expensive, around $5000 USD for the pump, and $300 USD a month for the infusion sites that last only 3 days each
- More complexity to use
- Still have to input carbs before eating
If you don't have certain issues, a pen saves you time, money, and is simpler to use. Pumps are suited for those who cannot manage their sugar levels well with pens. Usually this is children, very active people, or people with other diseases/medications that make their insulin resistance unpredictable.
The t:slim x2 and ypsopump are the best pumps on the market in my opinion. I believe the ypsopump is better for these reasons:
- You can set a lower limit, 79 (4.4) vs. 100 (5.0) on the t:slim.
- Less plastic waste as the cannula inserter is reusable.
- Works with the libre 3, which is about half the price compared to the dexcom g6 which the t:slim uses.
- I assume the algorithm is more advanced according to what someone told me but I have no evidence.
Children
If you have a child, I recommend watching this video by someone who was type 1 since a child and maintained around a 5.0 a1c since: https://www.youtube.com/watch?v=QHnSNneh7ck. A nondiabetic blood sugar average is especially important for children for proper brain and body development.
This is 99% to it. You'll get used to all of it relatively quickly so don't stress :)
Please reach out to me at [email protected] if you follow this guide and and let me know of your first a1c test. I made this guide on Mar 23, 2023, and update it every couple months. I added this sentence on Aug 7, 2024. In the past 1.5 years, no one reached out to me telling me what they thought of the guide or how it helped them despite it currently saying there are 547 views! It would be satisfying if I get proof that anyone got benefit from this :3
Optional sections
Edit: Apr 2024, I stopped using a cgm. I only eat lunch and dinner so on most days I test my blood 2 hours after meals.
Sometimes I will test right after waking up to see if my sleeping blood sugar was good. If my waking blood sugar is good for several days, I stop checking my waking blood sugar as it's been proven to be stable. You can save $1000-$3000 a year by just using a glucometer. It's also less mental burden as you are not seeing that number 24/7. With a cgm, sometimes after meals I would check multiple times an hour which is distracting. Test strips are more than enough for most situations. Save money, save mental attention by just going with test strips.
Dr.Bernstein
To learn more about the specifics of type 1 such as what to do when you are vomiting and possibly in DKA, check out Dr.Bernstein's diabetes playlist: https://www.youtube.com/watch?v=WFNGdKSXx64&list=PLs_TA02I6IvV-0SdUwE82Iw7iCCgbkJje&ab_channel=Dr.RichardK.Bernstein. He is a 80 year old endocrinologist who has been type 1 since he was 12 and has been practicing for 30 years. He reversed his long term complications such as severe kidney disease by having normal blood sugars. You don't have to follow everything he recommends to get good numbers though. He's a bit old school such as using syringes instead of insulin pens and using regular insulin which peaks in 2-3 hours. It has a longer acting time compared to fast acting insulin lispro (admelog/humalog) prescribed nowadays, which peaks in 1.5-2 hours. He gives a lot of practical information every type 1 should know such as what diseases may be related to type 1 such as hypothyroidism, how to handle unusually high blood sugars, how to know if you are in DKA, etc. Worth a watch.
alternative gluocose sensor app
Optional advice if you want a glucose sensor app better than the offical libre 2 or dexcom app. Especially in regards to the graph and alerts which I find to be a game changer. I use a app called xDrip+ which has a wayyy better graph. Here is an example of how it looks: https://xdrip.readthedocs.io/en/latest/use/mainUI/.
If you have a android you can use xDrip+. For iOS there is xDrip4iOS, although I haven't set it up with iOS before. I use android so all my steps below won't work for iOS. Android is easier for these diabetes apps since people can make apps without having to jump hoops Apple imposes.
If you have a iphone it's possible to use xDrip4iOS but it takes the installation time take 10x longer and it's a hassle. I recommend just getting an android, a cheap one is $200.
The steps below are probably incomplete and I am probably missing some details. Use it as a starting point.
Steps for libre 2 (android):
If you have a libre 2, you will need 3 apps: the official app, Diabox to intercept and get the readings, and xDrip+ for a nice graph and alerts.
You will only use official app except to start your sensor.
You can get Diabox online here, android only: https://github.com/Bubblandevteam/diabox/releases. Download the .apk, that's the app file, you can install it after downloading. Diabox is not on the play store since libre 2 manufacturer would block it on copyright grounds. It will get the readings through bluetooth automatically every 5 minutes and eliminate the need to scan. The ability is there for the libre 2 to read through bluetooth but the default app doesn't implement it.
You can download xDrip+ here: https://jamorham.github.io/#xdrip-plus. Diabox sends the the readings on to xDrip+. xDrip+ can't connect to the libre 2 directly. xDrip+ is used for the nice looking graph and customizable alerts. I also like how on the lock screen you can have the number and graph show, no need to unlock phone and open app. The app can also tell you your average a1c for the day and for a period up to 2 weeks.
Steps for dexcom g6 (android):
If you have a dexcom g6, xDrip+ can communciate directly with the dexcom, activate the sensor, and everything.
If your endo wants to see your readings, you can't use only xDrip+ as it can't share readings to Dexcom Clarity. Honestly I'd just show your endo your xDrip+ readings from your phone. They are probably clueless on how to read your graph and what it means.
But if you really want them to have access on their side, you can download a modified version of the official dexcom app which can send the readings to xDrip+ just like Diabox. Then on the modified official dexcom app you can share your readings with your endo. I had to use this for a clinical trial I'm in so that the study researcher would get my data. Link to the modified app post: https://www.reddit.com/r/dexcom/comments/y4vixk/oc_build_your_own_dexcom_app_update_now_with_g7/.
Steps for dexcom g6 (iphone):
xDrip4iOS should do everything. But it's a pain to set up since you need to purchase a developer certificate I believe. I haven't tried it.
how to reuse dexcom g6 sensors
A dexcom sensor is advertised to last 10 days. But you can actually restart them again for 10 days and get more life out of them. Many diabetics on reddit say they've done this. I average a few more days more than the advertised 10 days before the sensor readings go wonky or the adhesive falls off. I don't use skin grip patches on top of the sensor yet, usually the readings become too wonky before the adhesive peels off more than what is needed. If you want to save money and reduce waste, do this:
- End session/let sensor expire.
- Remove transmitter. A guitar pick works best. A test strip may work if the ones you use are strong enough. There is 1 key clip on each side you want to remove. Here is a video to help: https://www.youtube.com/watch?v=bxVSiutmbuQ
- Turn off bluetooth on your phone for 20 minutes.
- Turn on bluetooth and put the transmitter back into the sensor.
- Use the same sensor code to activate it and after warm up, do not calibrate for 1 hour.
- If the reading is off after an hour, calibrate it by 25% max at a time. So if the g6 says you are at a 9 but you are at a 5, tell it you are at a 7 with 2 back to back calibrations. Then 30 minutes later tell it you are at a 5, with 2 back to back calibrations. I find that if you tell it you are at a 5 immedietly after warm up, it does not comply, unlike a new sensor. A restarted sensor is harder to convince.